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Proximal Periprosthetic Femur Fractures: Strategies for Internal Fixation
The rate of total hip arthroplasty (THA) is rising and demand is expected to increase by 174% to 572,000 by 2030.1 The rate of periprosthetic fracture around primary THA is frequently reported at around 1%,2-4 though a recent study of over 32,000 THAs quotes the 20-year probability of periprosthetic fracture at 3.5%.5 Revision THA is also increasing in frequency and associated rates of periprosthetic fracture range from 1.5% to 7.8% following revision THA,3,4,6 with the probability of fracture at 20 years of 11%.7 Projection models predict that the number of periprosthetic fractures will rise by 4.6% per decade over the next 30 years.8
Broadly, treatment options include open reduction internal fixation (ORIF), revision THA, and combined approaches. The Vancouver classification, based on fracture location, stem stability, and bone loss, is often used to guide fracture treatment, with stable implants treated with ORIF and unstable implants requiring revision arthroplasty.
Fixation strategies for treatment of periprosthetic fracture around a well-fixed arthroplasty stem have evolved over time, and there continue to be a variety of available internal fixation options with no clear consensus on the optimal strategy.9 Rates of reoperation following ORIF of periprosthetic femur fracture are reported from 13% to 23%,8,10-12 confirming that there remains room for improvement in management of these injuries.
Locking Plate Fixation
Early fixation strategies included allograft and cables alone as well as nonlocked plate and cerclage constructs. In response to the complication and reoperation rate for nonlocked plate constructs, reported at 33%,13 locking plates were introduced as a treatment option, allowing for both improved osseous vascularity and added screw options.14 When compared to the traditional nonlocked Ogden construct, locking plate constructs are more resistant to axial and torsional load.15 Clinically, the relative risk of nonunion after nonlocking plate fixation is reported at 11.9 times that of fixation with locking plate technology.16
Successful use of lateral locking plate fixation for treatment of this injury has been reported on in several clinical series.17-20 Froberg and colleagues12 evaluated 60 Vancouver B1 and C fractures treated by locking plate osteosynthesis and reported no nonunions, an improvement from previous constructs. However, 8 out of 60 patients with 2-year follow-up required reoperation—4 for infection, 3 for refracture, and 1 for stem loosening—making it clear that the locking plate alone was not a panacea.
With locking plate fixation a mainstay of modern treatment of periprosthetic femur fractures, many questions still remain.
Proximal Fixation
Even with the introduction of locked plates, treatment success after ORIF of Vancouver B1 fractures relies on adequate proximal fixation. Options for proximal fixation around the stem include cerclage wires or cables, unicortical locked screws, obliquely directed bicortical screws, and use of the locking attachment plate to insert bicortical locked screws. These strategies can be used in the presence of cemented or uncemented stems, with biomechanical evidence that screw fixation through the cement mantle does not cause failure.21
Several biomechanical studies address the stiffness and strength of varying proximal fixation strategies. While early fixation relied heavily on cables, the use of cables alone as proximal fixation has been linked to significantly higher rates of failure when compared to other constructs in a large clinical series.11 Multiple biomechanical studies have shown that newer methods of proximal fixation provide more rigid constructs.22,23
Unicortical locked screws appear to outperform cables biomechanically. The use of unicortical screws in lieu of or in addition to cables provides added resistance to lateral bending as well as torsion when compared to cables alone.24 A second group found that unicortical locked screws alone were superior to combined fixation with cerclage wires and unicortical locked screws.25
Added stability can be demonstrated by bicortical fixation strategies, which offer increased rigidity when compared to cables or unicortical screws.22 In vitro work has shown enhanced fixation stability with bicortical screw fixation using the locking attachment plate when compared to cerclage wires alone.23,26 Clinically, some authors have demonstrated success with the use of reversed distal femoral locking plates in order to enhance proximal locking options and allow for bicortical fixation around the stem.19 As noted above, the data favor the opinion that clinical failure rates with cerclage wires alone are high, and biomechanically, bicortical fixation around the femoral stem appears to be superior to unicortical locked screw fixation or cerclage wires. If rigid proximal fixation is desired, an effort should be made to obtain bicortical fixation around the femoral stem.
Allograft
Allograft strut, either alone or in addition to plate osteosynthesis, has long been used in treatment of periprosthetic fractures. Proponents of this technique cite improved biomechanical stability17 and allograft incorporation resulting in restoration of bone stock.
Early treatment of periprosthetic femur fractures consisted solely of allograft and cable fixation, but data on the technique is limited. A small series reported reasonable success, with only 2 out of 19 patients developing nonunion.27 More recently Haddad and colleagues28 reported malunions in 3 out of 19 patients treated with allograft and cables alone. Allograft alone has been largely abandoned in favor of plate fixation, and biomechanical evidence shows that plate and screw or cerclage constructs are more resistant to torsion and lateral bending than allograft with cables alone.29
However, the role of allograft in treatment of periprosthetic femur fractures is not clearly defined. Some authors advocate routinely supplementing plate fixation with allograft28,30 and others go as far as to suggest superior union rates of strut allograft augmented plate fixation when compared to plate fixation alone for periprosthetic fractures around a stable femoral stem.31 However, in that series, the failure rate of 5/11 patients treated with plate alone is higher than current series,12 and others have demonstrated good success without allograft, even with nonlocked plates.32
As recently as 2016, a lateral locking plate supplemented with allograft has been described as a successful technique, with no nonunions reported in a small series.30 However, without a comparison group, it is unclear what role the allograft plays in success in that construct.
Despite some proposed benefits, the additional soft tissue stripping required to place allograft has raised the question of delayed healing and increased infection rate as a result of this technique. A systematic review by Moore and colleagues33 looking at the use of allograft strut in Vancouver B1 fractures found increased time to union (4.4 vs 6.6 months) and deep infection rate (3.8% vs 8.3%) with the use of allograft strut, leading them to recommend cautious use of allograft when treating Vancouver B1 fractures.
With improved fixation strategies available, the role of allograft may be best reserved for patients with inadequate bone stock.
Dual Plate Fixation
Dual plate fixation has been proposed as one mechanism to increase construct strength. A periprosthetic fracture model has shown that, biomechanically, orthogonal plates have higher bending stiffness, torsional stiffness, cycles to failure, and load to failure when compared to a single lateral plate with use of a locking attachment plate proximally.34 Choi and colleagues35 compared lateral locking plates alone, lateral locking plates with allograft, and lateral locking plates with an orthogonal anterior plate and found the addition of an anterior plate resulted in the strongest construct.
Clinically, Müller and colleagues36 reported on a series of 10 patients treated with orthogonal (anterior and lateral) plating for periprosthetic femur fractures, including 3 nonunions. In their series, there was 1 plate failure and they conclude that dual plating is not associated with an increased risk of complications, and can also be used as a salvage procedure.
While the evidence for dual plating is limited, it may provide needed additional stability in certain cases without the added cost and exposure required for allograft.
Minimally Invasive Plate Osteosynthesis
Contrary to the extensive exposure required to place allograft, minimally invasive plate osteosynthesis (MIPO) of periprosthetic femur fractures is advocated by some authors.18,20 Ricci and colleagues18 reported no nonunions in 50 patients treated with indirect reduction techniques and laterally based plating alone without use of allograft. A combination of cables, locking, and nonlocking screws were used. Critical to their technique was preservation of the soft tissue envelope at the level of the fracture.
In further support of MIPO techniques, a systematic review of 1571 periprosthetic hip fractures reported significantly increased risk of nonunion with open approaches when compared to minimally invasive osteosynthesis,16 emphasizing the role of preservation of vascularity in treating these fractures.
Length of Fixation
For some time it was recommended that fixation of Vancouver B1 fractures end 2 cortical diameters below the level of the fracture.37,38 More recently there has been interest in the potential benefits of increased length of fixation.
A biomechanical study comparing long (20-hole) and short (12-hole) plates for periprosthetic fracture with regard to failure found no difference in failure rates between groups.39 While plate length did not appear to affect construct stiffness, the issue of subsequent fracture distal to the construct remains.
Moloney and colleagues40 proposed fixation of Vancouver B1 fractures using plates that span the length of the femur to the level of the femoral condyles to minimize peri-implant failures in osteoporotic patients. In 36 patients treated with standard-length plates, there were 2 fractures distal to the previous fixation compared to no subsequent fractures in 21 patients treated with spanning fixation.
Similarly, in Vancouver C fractures there is some evidence that fixation should span the femoral stem, regardless of available bone for fixation proximal to the fracture. Kubiak and colleagues41 found increasing load to failure and decreased cortical strain in a biomechanical model comparing plates that stop short of the femoral stem with those that span the stem.
Clinically, this concept is supported by Froberg and colleagues.12 In their series of 60 Vancouver B1 and C fractures treated with laterally based locked plating, 3 patients went on to refracture. All of these fractures occurred in patients with Vancouver C fractures treated with plates overlapping the preexisting stem by <50%. The fractures all occurred at the high stress area between the tip of the stem and the end of the plate.
Further support of extended plate length comes from Drew and colleagues,8 who demonstrated a significantly decreased risk of reoperation following ORIF of periprosthetic femur fracture when >75% of the length of the femur was spanned compared to <50%. Although in some settings short fixation may produce satisfactory results, consideration should be given to extending the length of fixation, especially in the osteoporotic population.
Interprosthetic Fractures
With a rising number of patients with ipsilateral hip and knee arthroplasty, the rate of interprosthetic fractures is rising. These fractures present additional challenges given preexisting implants above and below the level of the fracture. The use of a single precontoured laterally based locked plate has been reported with good union rates approaching 90%.42,43 In one series, all nonunions occurred in Vancouver B1 fractures,43 again bringing to light the challenging nature of the B1 fracture.
Nonunion
Success in treating periprosthetic femur fractures has improved with improved fixation methods and understanding of technique. However, current rates of nonunion are still reported up to 27% for B1 and C fractures.44
There is limited evidence on the treatment of periprosthetic femur fracture nonunion. However, treatment is difficult and complication rates are high. Crockarell and colleagues45 reported a 52% overall complication rate in their series of 23 periprosthetic femur fracture nonunions.
Nonunions of the femur near a prosthesis can be treated by revision of the fracture fixation using compression and grafting to achieve bone healing vs revision of the joint prosthesis to span the area of the nonunited bone. Case-by-case decision-making is based on the remaining bone stock and the type of revision prosthesis necessary to span the problem area. Given the challenges associated with their treatment, a focus on prevention of nonunion is of paramount importance.
Authors’ Preferred Treatment
Our treatment of periprosthetic femur fractures with a well-fixed hip arthroplasty stem adheres to the principles supported in the literature (Figures 1A-1D and Figures 2A, 2B).
- Soft tissue friendly dissection with limited exposure at the fracture site is preferred as the fracture allows, particularly in cases with comminution where a direct assessment of the reduction is not available.
- Plate fixation strategy is dictated by the characteristics of the fracture. Fracture patterns amenable to anatomic reduction receive interfragmentary compression and absolute stability constructs. Highly comminuted fractures receive relatively stable bridging constructs to encourage callous.
- Locking screws are used rarely in diaphyseal fracture patterns, and when employed, are applied to only one side of the fracture to limit “over stiffening” the construct.
- Liberal use of dual plating, both as a method of maintaining fracture reduction while a structural plate is applied and increasing construct rigidity.
- Proximal fixation relies heavily on bicortical screws placed through the holes of the lateral plate. Cerclage wires and unicortical screws are rarely used in our practice. In the case of larger stems, a bicortical 3.5-mm screw can be placed through a 4.5-mm plate using a reduction washer.
Summary
Techniques for treatment of periprosthetic femur fractures around a well-fixed hip arthroplasty stem are constantly evolving. Several principles have emerged to decrease rates of treatment failure and subsequent reoperation. While there are several methods to do so, it is critical to achieve stable proximal fixation. Long spanning fixation constructs are linked to lower failure and reoperation rates in both B1 and C type fractures. Additionally, the importance of soft tissue management and maintenance of local vascularity should not be underestimated.
1. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785.
2. Lewallen DG, Berry DJ. Periprosthetic fracture of the femur after total hip arthroplasty: treatment and results to date. Instr Course Lect. 1998;47:243-249.
3. Kavanagh BF. Femoral fractures associated with total hip arthroplasty. Orthop Clin North Am. 1992;23(2):249-257.
4. Meek RM, Norwood T, Smith R, Brenkel IJ, Howie CR. The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg Br. 2011;93(1):96-101.
5. Abdel MP, Watts CD, Houdek MT, Lewallen DG, Berry DJ. Epidemiology of periprosthetic fracture of the femur in 32 644 primary total hip arthroplasties: a 40-year experience. Bone Joint J. 2016;98-B(4):461-467.
6. Berry DJ. Epidemiology: hip and knee. Orthop Clin North Am. 1999;30(2):183-190.
7. Abdel MP, Houdek MT, Watts CD, Lewallen DG, Berry DJ. Epidemiology of periprosthetic femoral fractures in 5417 revision total hip arthrolasties: a 40-year experience. Bone Joint J. 2016;98-B(4):468-474.
8. Drew JM, Griffin WL, Odum SM, Van Doren B, Weston BT, Stryker LS. Survivorship after periprosthetic femur fracture: factors affecting outcome. J Arthroplasty. 2015. [Epub ahead of print]
9. Dehghan N, McKee MD, Nauth A, Ristevski B, Schemitsch EH. Surgical fixation of Vancouver type B1 periprosthetic femur fractures: a systematic review. J Orthop Trauma. 2014;28(12):721-727.
10. Mukundan C, Rayan F, Kheir E, Macdonald D. Management of late periprosthetic femur fractures: a retrospective cohort of 72 patients. Int Orthop. 2010;34(4):485-489.
11. Lindahl H, Malchau H, Odén A, Garellick G. Risk factors for failure after treatment of a periprosthetic fracture of the femur. J Bone Joint Surg Br. 2006;88(1):26-30.
12. Froberg L, Troelsen A, Brix M. Periprosthetic Vancouver type B1 and C fractures treated by locking-plate osteosynthesis: fracture union and reoperations in 60 consecutive fractures. Acta Orthop. 2012;83(6):648-652.
13. Beals RK, Tower SS. Periprosthetic fractures of the femur. An analysis of 93 fractures. Clin Orthop Relat Res. 1996(327):238-246.
14. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br. 2002;84(8):1093-1110.
15. Fulkerson E, Koval K, Preston CF, Iesaka K, Kummer FJ, Egol KA. Fixation of periprosthetic femoral shaft fractures associated with cemented femoral stems: a biomechanical comparison of locked plating and conventional cable plates. J Orthop Trauma. 2006;20(2):89-93.
16. Stoffel K, Sommer C, Kalampoki V, Blumenthal A, Joeris A. The influence of the operation technique and implant used in the treatment of periprosthetic hip and interprosthetic femur fractures: a systematic literature review of 1571 cases. Arch Orthop Trauma Surg. 2016;136(4):553-561.
17. Fulkerson E, Tejwani N, Stuchin S, Egol K. Management of periprosthetic femur fractures with a first generation locking plate. Injury. 2007;38(8):965-972.
18. Ricci WM, Bolhofner BR, Loftus T, Cox C, Mitchell S, Borrelli J Jr. Indirect reduction and plate fixation, without grafting, for periprosthetic femoral shaft fractures about a stable intramedullary implant. Surgical technique. J Bone Joint Surg Am. 2006;88 Suppl 1 Pt 2:275-282.
19. Ebraheim NA, Gomez C, Ramineni SK, Liu J. Fixation of periprosthetic femoral shaft fractures adjacent to a well-fixed femoral stem with reversed distal femoral locking plate. J Trauma. 2009;66(4):1152-1157.
20. Bryant GK, Morshed S, Agel J, et al. Isolated locked compression plating for Vancouver Type B1 periprosthetic femoral fractures. Injury. 2009;40(11):1180-1186.
21. Giesinger K, Ebneter L, Day RE, Stoffel KK, Yates PJ, Kuster MS. Can plate osteosynthesis of periprosthethic femoral fractures cause cement mantle failure around a stable hip stem? A biomechanical analysis. J Arthroplasty. 2014;29(6):1308-1312.
22. Lewis GS, Caroom CT, Wee H, et al. Tangential bicortical locked fixation improves stability in vancouver B1 periprosthetic femur fractures: a biomechanical study. J Orthop Trauma. 2015;29(10):e364-e370.
23. Lenz M, Perren SM, Gueorguiev B, et al. A biomechanical study on proximal plate fixation techniques in periprosthetic femur fractures. Injury. 2014;45 Suppl 1:S71-S75.
24. Dennis MG, Simon JA, Kummer FJ, Koval KJ, DiCesare PE. Fixation of periprosthetic femoral shaft fractures occurring at the tip of the stem: a biomechanical study of 5 techniques. J Arthroplasty. 2000;15(4):523-528.
25. Graham SM, Mak JH, Moazen M, et al. Periprosthetic femoral fracture fixation: a biomechanical comparison between proximal locking screws and cables. J Orthop Sci. 2015;20(5):875-880.
26. Griffiths JT, Taheri A, Day RE, Yates PJ. Better axial stiffness of a bicortical screw construct compared to a cable construct for comminuted Vancouver B1 proximal femoral fractures. J Arthroplasty. 2015;30(12):2333-2337.
27. Chandler HP, King D, Limbird R, et al. The use of cortical allograft struts for fixation of fractures associated with well-fixed total joint prostheses. Semin Arthroplasty. 1993;4(2):99-107.
28. Haddad FS, Duncan CP, Berry DJ, Lewallen DG, Gross AE, Chandler HP. Periprosthetic femoral fractures around well-fixed implants: use of cortical onlay allografts with or without a plate. J Bone Joint Surg Am. 2002;84-A(6):945-950.
29. Dennis MG, Simon JA, Kummer FJ, Koval KJ, Di Cesare PE. Fixation of periprosthetic femoral shaft fractures: a biomechanical comparison of two techniques. J Orthop Trauma. 2001;15(3):177-180.
30. Yeo I, Rhyu KH, Kim SM, Park YS, Lim SJ. High union rates of locking compression plating with cortical strut allograft for type B1 periprosthetic femoral fractures. Int Orthop. 2016. [Epub ahead of print]
31. Khashan M, Amar E, Drexler M, Chechik Ok, Cohen Z, Steinberg EL. Superior outcome of strut allograft-augmented plate fixation for the treatment of periprosthetic fractures around a stable femoral stem. Injury. 2013;44(11):1556-1560.
32. Old AB, McGrory BJ, White RR, Babikian GM. Fixation of Vancouver B1 peri-prosthetic fractures by broad metal plates without the application of strut allografts. J Bone Joint Surg Br. 2006;88(11):1425-1429.
33. Moore RE, Baldwin K, Austin MS, Mehta S. A systematic review of open reduction and internal fixation of periprosthetic femur fractures with or without allograft strut, cerclage, and locked plates. J Arthroplasty. 2014;29(5):872-876.
34. Lenz M, Stoffel K, Gueorguiev B, Klos K, Kielstein H, Hofmann GO. Enhancing fixation strength in periprosthetic femur fractures by orthogonal plating-a biomechanical study. J Orthop Res. 2016;34(4):591-596.
35. Choi JK, Gardner TR, Yoon E, Morrison TA, Macaulay WB, Geller JA. The effect of fixation technique on the stiffness of comminuted Vancouver B1 periprosthetic femur fractures. J Arthroplasty. 2010;25(6 Suppl):124-128.
36. Müller FJ, Galler M Füchtmeier B. Clinical and radiological results of patients treated with orthogonal double plating for periprosthetic femoral fractures. Int Orthop. 2014;38(12):2469-2472.
37. Pike J, Davidson D, Garbuz D, Duncan CP, O’Brien PJ, Masri BA. Principles of treatment for periprosthetic femoral shaft fractures around well-fixed total hip arthroplasty. J Am Acad Orthop Surg. 2009;17(11):677-688.
38. Serocki JH, Chandler RW, Dorr LD. Treatment of fractures about hip prostheses with compression plating. J Arthroplasty. 1992;7(2):129-135.
39. Pletka JD, Marsland D, Belkoff SM, Mears SC, Kates SL. Biomechanical comparison of 2 different locking plate fixation methods in vancouver b1 periprosthetic femur fractures. Geriatr Orthop Surg Rehabil. 2011;2(2):51-55.
40. Moloney GB, Westrick ER, Siska PA, Tarkin IS. Treatment of periprosthetic femur fractures around a well-fixed hip arthroplasty implant: span the whole bone. Arch Orthop Trauma Surg. 2014;134(1):9-14.
41. Kubiak EN, Haller JM, Kemper DD, Presson AP, Higgins TF, Horowitz DS. Does the lateral plate need to overlap the stem to mitigate stress concentration when treating Vancouver C periprosthetic supracondylar femur fracture? J Arthroplasty. 2015;30(1):104-108.
42. Sah AP, Marshall A, Virkus WV, Estok DM 2nd, Della Valle CJ. Interprosthetic fractures of the femur: treatment with a single-locked plate. J Arthroplasty. 2010;25(2):280-286.
43. Hoffmann MF, Lotzien S, Schildhauer TA. Clinical outcome of interprosthetic femoral fractures treated with polyaxial locking plates. Injury. 2016. [Epub ahead of print]
44. Holder N, Papp S, Gofton W, Beaulé PE. Outcomes following surgical treatment of periprosthetic femur fractures: a single centre series. Can J Surg. 2014;57(3):209-213.
45. Crockarell JR Jr, Berry DJ, Lewallen DG. Nonunion after periprosthetic femoral fracture associated with total hip arthroplasty. J Bone Joint Surg Am. 1999;81(8):1073-1079.
The rate of total hip arthroplasty (THA) is rising and demand is expected to increase by 174% to 572,000 by 2030.1 The rate of periprosthetic fracture around primary THA is frequently reported at around 1%,2-4 though a recent study of over 32,000 THAs quotes the 20-year probability of periprosthetic fracture at 3.5%.5 Revision THA is also increasing in frequency and associated rates of periprosthetic fracture range from 1.5% to 7.8% following revision THA,3,4,6 with the probability of fracture at 20 years of 11%.7 Projection models predict that the number of periprosthetic fractures will rise by 4.6% per decade over the next 30 years.8
Broadly, treatment options include open reduction internal fixation (ORIF), revision THA, and combined approaches. The Vancouver classification, based on fracture location, stem stability, and bone loss, is often used to guide fracture treatment, with stable implants treated with ORIF and unstable implants requiring revision arthroplasty.
Fixation strategies for treatment of periprosthetic fracture around a well-fixed arthroplasty stem have evolved over time, and there continue to be a variety of available internal fixation options with no clear consensus on the optimal strategy.9 Rates of reoperation following ORIF of periprosthetic femur fracture are reported from 13% to 23%,8,10-12 confirming that there remains room for improvement in management of these injuries.
Locking Plate Fixation
Early fixation strategies included allograft and cables alone as well as nonlocked plate and cerclage constructs. In response to the complication and reoperation rate for nonlocked plate constructs, reported at 33%,13 locking plates were introduced as a treatment option, allowing for both improved osseous vascularity and added screw options.14 When compared to the traditional nonlocked Ogden construct, locking plate constructs are more resistant to axial and torsional load.15 Clinically, the relative risk of nonunion after nonlocking plate fixation is reported at 11.9 times that of fixation with locking plate technology.16
Successful use of lateral locking plate fixation for treatment of this injury has been reported on in several clinical series.17-20 Froberg and colleagues12 evaluated 60 Vancouver B1 and C fractures treated by locking plate osteosynthesis and reported no nonunions, an improvement from previous constructs. However, 8 out of 60 patients with 2-year follow-up required reoperation—4 for infection, 3 for refracture, and 1 for stem loosening—making it clear that the locking plate alone was not a panacea.
With locking plate fixation a mainstay of modern treatment of periprosthetic femur fractures, many questions still remain.
Proximal Fixation
Even with the introduction of locked plates, treatment success after ORIF of Vancouver B1 fractures relies on adequate proximal fixation. Options for proximal fixation around the stem include cerclage wires or cables, unicortical locked screws, obliquely directed bicortical screws, and use of the locking attachment plate to insert bicortical locked screws. These strategies can be used in the presence of cemented or uncemented stems, with biomechanical evidence that screw fixation through the cement mantle does not cause failure.21
Several biomechanical studies address the stiffness and strength of varying proximal fixation strategies. While early fixation relied heavily on cables, the use of cables alone as proximal fixation has been linked to significantly higher rates of failure when compared to other constructs in a large clinical series.11 Multiple biomechanical studies have shown that newer methods of proximal fixation provide more rigid constructs.22,23
Unicortical locked screws appear to outperform cables biomechanically. The use of unicortical screws in lieu of or in addition to cables provides added resistance to lateral bending as well as torsion when compared to cables alone.24 A second group found that unicortical locked screws alone were superior to combined fixation with cerclage wires and unicortical locked screws.25
Added stability can be demonstrated by bicortical fixation strategies, which offer increased rigidity when compared to cables or unicortical screws.22 In vitro work has shown enhanced fixation stability with bicortical screw fixation using the locking attachment plate when compared to cerclage wires alone.23,26 Clinically, some authors have demonstrated success with the use of reversed distal femoral locking plates in order to enhance proximal locking options and allow for bicortical fixation around the stem.19 As noted above, the data favor the opinion that clinical failure rates with cerclage wires alone are high, and biomechanically, bicortical fixation around the femoral stem appears to be superior to unicortical locked screw fixation or cerclage wires. If rigid proximal fixation is desired, an effort should be made to obtain bicortical fixation around the femoral stem.
Allograft
Allograft strut, either alone or in addition to plate osteosynthesis, has long been used in treatment of periprosthetic fractures. Proponents of this technique cite improved biomechanical stability17 and allograft incorporation resulting in restoration of bone stock.
Early treatment of periprosthetic femur fractures consisted solely of allograft and cable fixation, but data on the technique is limited. A small series reported reasonable success, with only 2 out of 19 patients developing nonunion.27 More recently Haddad and colleagues28 reported malunions in 3 out of 19 patients treated with allograft and cables alone. Allograft alone has been largely abandoned in favor of plate fixation, and biomechanical evidence shows that plate and screw or cerclage constructs are more resistant to torsion and lateral bending than allograft with cables alone.29
However, the role of allograft in treatment of periprosthetic femur fractures is not clearly defined. Some authors advocate routinely supplementing plate fixation with allograft28,30 and others go as far as to suggest superior union rates of strut allograft augmented plate fixation when compared to plate fixation alone for periprosthetic fractures around a stable femoral stem.31 However, in that series, the failure rate of 5/11 patients treated with plate alone is higher than current series,12 and others have demonstrated good success without allograft, even with nonlocked plates.32
As recently as 2016, a lateral locking plate supplemented with allograft has been described as a successful technique, with no nonunions reported in a small series.30 However, without a comparison group, it is unclear what role the allograft plays in success in that construct.
Despite some proposed benefits, the additional soft tissue stripping required to place allograft has raised the question of delayed healing and increased infection rate as a result of this technique. A systematic review by Moore and colleagues33 looking at the use of allograft strut in Vancouver B1 fractures found increased time to union (4.4 vs 6.6 months) and deep infection rate (3.8% vs 8.3%) with the use of allograft strut, leading them to recommend cautious use of allograft when treating Vancouver B1 fractures.
With improved fixation strategies available, the role of allograft may be best reserved for patients with inadequate bone stock.
Dual Plate Fixation
Dual plate fixation has been proposed as one mechanism to increase construct strength. A periprosthetic fracture model has shown that, biomechanically, orthogonal plates have higher bending stiffness, torsional stiffness, cycles to failure, and load to failure when compared to a single lateral plate with use of a locking attachment plate proximally.34 Choi and colleagues35 compared lateral locking plates alone, lateral locking plates with allograft, and lateral locking plates with an orthogonal anterior plate and found the addition of an anterior plate resulted in the strongest construct.
Clinically, Müller and colleagues36 reported on a series of 10 patients treated with orthogonal (anterior and lateral) plating for periprosthetic femur fractures, including 3 nonunions. In their series, there was 1 plate failure and they conclude that dual plating is not associated with an increased risk of complications, and can also be used as a salvage procedure.
While the evidence for dual plating is limited, it may provide needed additional stability in certain cases without the added cost and exposure required for allograft.
Minimally Invasive Plate Osteosynthesis
Contrary to the extensive exposure required to place allograft, minimally invasive plate osteosynthesis (MIPO) of periprosthetic femur fractures is advocated by some authors.18,20 Ricci and colleagues18 reported no nonunions in 50 patients treated with indirect reduction techniques and laterally based plating alone without use of allograft. A combination of cables, locking, and nonlocking screws were used. Critical to their technique was preservation of the soft tissue envelope at the level of the fracture.
In further support of MIPO techniques, a systematic review of 1571 periprosthetic hip fractures reported significantly increased risk of nonunion with open approaches when compared to minimally invasive osteosynthesis,16 emphasizing the role of preservation of vascularity in treating these fractures.
Length of Fixation
For some time it was recommended that fixation of Vancouver B1 fractures end 2 cortical diameters below the level of the fracture.37,38 More recently there has been interest in the potential benefits of increased length of fixation.
A biomechanical study comparing long (20-hole) and short (12-hole) plates for periprosthetic fracture with regard to failure found no difference in failure rates between groups.39 While plate length did not appear to affect construct stiffness, the issue of subsequent fracture distal to the construct remains.
Moloney and colleagues40 proposed fixation of Vancouver B1 fractures using plates that span the length of the femur to the level of the femoral condyles to minimize peri-implant failures in osteoporotic patients. In 36 patients treated with standard-length plates, there were 2 fractures distal to the previous fixation compared to no subsequent fractures in 21 patients treated with spanning fixation.
Similarly, in Vancouver C fractures there is some evidence that fixation should span the femoral stem, regardless of available bone for fixation proximal to the fracture. Kubiak and colleagues41 found increasing load to failure and decreased cortical strain in a biomechanical model comparing plates that stop short of the femoral stem with those that span the stem.
Clinically, this concept is supported by Froberg and colleagues.12 In their series of 60 Vancouver B1 and C fractures treated with laterally based locked plating, 3 patients went on to refracture. All of these fractures occurred in patients with Vancouver C fractures treated with plates overlapping the preexisting stem by <50%. The fractures all occurred at the high stress area between the tip of the stem and the end of the plate.
Further support of extended plate length comes from Drew and colleagues,8 who demonstrated a significantly decreased risk of reoperation following ORIF of periprosthetic femur fracture when >75% of the length of the femur was spanned compared to <50%. Although in some settings short fixation may produce satisfactory results, consideration should be given to extending the length of fixation, especially in the osteoporotic population.
Interprosthetic Fractures
With a rising number of patients with ipsilateral hip and knee arthroplasty, the rate of interprosthetic fractures is rising. These fractures present additional challenges given preexisting implants above and below the level of the fracture. The use of a single precontoured laterally based locked plate has been reported with good union rates approaching 90%.42,43 In one series, all nonunions occurred in Vancouver B1 fractures,43 again bringing to light the challenging nature of the B1 fracture.
Nonunion
Success in treating periprosthetic femur fractures has improved with improved fixation methods and understanding of technique. However, current rates of nonunion are still reported up to 27% for B1 and C fractures.44
There is limited evidence on the treatment of periprosthetic femur fracture nonunion. However, treatment is difficult and complication rates are high. Crockarell and colleagues45 reported a 52% overall complication rate in their series of 23 periprosthetic femur fracture nonunions.
Nonunions of the femur near a prosthesis can be treated by revision of the fracture fixation using compression and grafting to achieve bone healing vs revision of the joint prosthesis to span the area of the nonunited bone. Case-by-case decision-making is based on the remaining bone stock and the type of revision prosthesis necessary to span the problem area. Given the challenges associated with their treatment, a focus on prevention of nonunion is of paramount importance.
Authors’ Preferred Treatment
Our treatment of periprosthetic femur fractures with a well-fixed hip arthroplasty stem adheres to the principles supported in the literature (Figures 1A-1D and Figures 2A, 2B).
- Soft tissue friendly dissection with limited exposure at the fracture site is preferred as the fracture allows, particularly in cases with comminution where a direct assessment of the reduction is not available.
- Plate fixation strategy is dictated by the characteristics of the fracture. Fracture patterns amenable to anatomic reduction receive interfragmentary compression and absolute stability constructs. Highly comminuted fractures receive relatively stable bridging constructs to encourage callous.
- Locking screws are used rarely in diaphyseal fracture patterns, and when employed, are applied to only one side of the fracture to limit “over stiffening” the construct.
- Liberal use of dual plating, both as a method of maintaining fracture reduction while a structural plate is applied and increasing construct rigidity.
- Proximal fixation relies heavily on bicortical screws placed through the holes of the lateral plate. Cerclage wires and unicortical screws are rarely used in our practice. In the case of larger stems, a bicortical 3.5-mm screw can be placed through a 4.5-mm plate using a reduction washer.
Summary
Techniques for treatment of periprosthetic femur fractures around a well-fixed hip arthroplasty stem are constantly evolving. Several principles have emerged to decrease rates of treatment failure and subsequent reoperation. While there are several methods to do so, it is critical to achieve stable proximal fixation. Long spanning fixation constructs are linked to lower failure and reoperation rates in both B1 and C type fractures. Additionally, the importance of soft tissue management and maintenance of local vascularity should not be underestimated.
The rate of total hip arthroplasty (THA) is rising and demand is expected to increase by 174% to 572,000 by 2030.1 The rate of periprosthetic fracture around primary THA is frequently reported at around 1%,2-4 though a recent study of over 32,000 THAs quotes the 20-year probability of periprosthetic fracture at 3.5%.5 Revision THA is also increasing in frequency and associated rates of periprosthetic fracture range from 1.5% to 7.8% following revision THA,3,4,6 with the probability of fracture at 20 years of 11%.7 Projection models predict that the number of periprosthetic fractures will rise by 4.6% per decade over the next 30 years.8
Broadly, treatment options include open reduction internal fixation (ORIF), revision THA, and combined approaches. The Vancouver classification, based on fracture location, stem stability, and bone loss, is often used to guide fracture treatment, with stable implants treated with ORIF and unstable implants requiring revision arthroplasty.
Fixation strategies for treatment of periprosthetic fracture around a well-fixed arthroplasty stem have evolved over time, and there continue to be a variety of available internal fixation options with no clear consensus on the optimal strategy.9 Rates of reoperation following ORIF of periprosthetic femur fracture are reported from 13% to 23%,8,10-12 confirming that there remains room for improvement in management of these injuries.
Locking Plate Fixation
Early fixation strategies included allograft and cables alone as well as nonlocked plate and cerclage constructs. In response to the complication and reoperation rate for nonlocked plate constructs, reported at 33%,13 locking plates were introduced as a treatment option, allowing for both improved osseous vascularity and added screw options.14 When compared to the traditional nonlocked Ogden construct, locking plate constructs are more resistant to axial and torsional load.15 Clinically, the relative risk of nonunion after nonlocking plate fixation is reported at 11.9 times that of fixation with locking plate technology.16
Successful use of lateral locking plate fixation for treatment of this injury has been reported on in several clinical series.17-20 Froberg and colleagues12 evaluated 60 Vancouver B1 and C fractures treated by locking plate osteosynthesis and reported no nonunions, an improvement from previous constructs. However, 8 out of 60 patients with 2-year follow-up required reoperation—4 for infection, 3 for refracture, and 1 for stem loosening—making it clear that the locking plate alone was not a panacea.
With locking plate fixation a mainstay of modern treatment of periprosthetic femur fractures, many questions still remain.
Proximal Fixation
Even with the introduction of locked plates, treatment success after ORIF of Vancouver B1 fractures relies on adequate proximal fixation. Options for proximal fixation around the stem include cerclage wires or cables, unicortical locked screws, obliquely directed bicortical screws, and use of the locking attachment plate to insert bicortical locked screws. These strategies can be used in the presence of cemented or uncemented stems, with biomechanical evidence that screw fixation through the cement mantle does not cause failure.21
Several biomechanical studies address the stiffness and strength of varying proximal fixation strategies. While early fixation relied heavily on cables, the use of cables alone as proximal fixation has been linked to significantly higher rates of failure when compared to other constructs in a large clinical series.11 Multiple biomechanical studies have shown that newer methods of proximal fixation provide more rigid constructs.22,23
Unicortical locked screws appear to outperform cables biomechanically. The use of unicortical screws in lieu of or in addition to cables provides added resistance to lateral bending as well as torsion when compared to cables alone.24 A second group found that unicortical locked screws alone were superior to combined fixation with cerclage wires and unicortical locked screws.25
Added stability can be demonstrated by bicortical fixation strategies, which offer increased rigidity when compared to cables or unicortical screws.22 In vitro work has shown enhanced fixation stability with bicortical screw fixation using the locking attachment plate when compared to cerclage wires alone.23,26 Clinically, some authors have demonstrated success with the use of reversed distal femoral locking plates in order to enhance proximal locking options and allow for bicortical fixation around the stem.19 As noted above, the data favor the opinion that clinical failure rates with cerclage wires alone are high, and biomechanically, bicortical fixation around the femoral stem appears to be superior to unicortical locked screw fixation or cerclage wires. If rigid proximal fixation is desired, an effort should be made to obtain bicortical fixation around the femoral stem.
Allograft
Allograft strut, either alone or in addition to plate osteosynthesis, has long been used in treatment of periprosthetic fractures. Proponents of this technique cite improved biomechanical stability17 and allograft incorporation resulting in restoration of bone stock.
Early treatment of periprosthetic femur fractures consisted solely of allograft and cable fixation, but data on the technique is limited. A small series reported reasonable success, with only 2 out of 19 patients developing nonunion.27 More recently Haddad and colleagues28 reported malunions in 3 out of 19 patients treated with allograft and cables alone. Allograft alone has been largely abandoned in favor of plate fixation, and biomechanical evidence shows that plate and screw or cerclage constructs are more resistant to torsion and lateral bending than allograft with cables alone.29
However, the role of allograft in treatment of periprosthetic femur fractures is not clearly defined. Some authors advocate routinely supplementing plate fixation with allograft28,30 and others go as far as to suggest superior union rates of strut allograft augmented plate fixation when compared to plate fixation alone for periprosthetic fractures around a stable femoral stem.31 However, in that series, the failure rate of 5/11 patients treated with plate alone is higher than current series,12 and others have demonstrated good success without allograft, even with nonlocked plates.32
As recently as 2016, a lateral locking plate supplemented with allograft has been described as a successful technique, with no nonunions reported in a small series.30 However, without a comparison group, it is unclear what role the allograft plays in success in that construct.
Despite some proposed benefits, the additional soft tissue stripping required to place allograft has raised the question of delayed healing and increased infection rate as a result of this technique. A systematic review by Moore and colleagues33 looking at the use of allograft strut in Vancouver B1 fractures found increased time to union (4.4 vs 6.6 months) and deep infection rate (3.8% vs 8.3%) with the use of allograft strut, leading them to recommend cautious use of allograft when treating Vancouver B1 fractures.
With improved fixation strategies available, the role of allograft may be best reserved for patients with inadequate bone stock.
Dual Plate Fixation
Dual plate fixation has been proposed as one mechanism to increase construct strength. A periprosthetic fracture model has shown that, biomechanically, orthogonal plates have higher bending stiffness, torsional stiffness, cycles to failure, and load to failure when compared to a single lateral plate with use of a locking attachment plate proximally.34 Choi and colleagues35 compared lateral locking plates alone, lateral locking plates with allograft, and lateral locking plates with an orthogonal anterior plate and found the addition of an anterior plate resulted in the strongest construct.
Clinically, Müller and colleagues36 reported on a series of 10 patients treated with orthogonal (anterior and lateral) plating for periprosthetic femur fractures, including 3 nonunions. In their series, there was 1 plate failure and they conclude that dual plating is not associated with an increased risk of complications, and can also be used as a salvage procedure.
While the evidence for dual plating is limited, it may provide needed additional stability in certain cases without the added cost and exposure required for allograft.
Minimally Invasive Plate Osteosynthesis
Contrary to the extensive exposure required to place allograft, minimally invasive plate osteosynthesis (MIPO) of periprosthetic femur fractures is advocated by some authors.18,20 Ricci and colleagues18 reported no nonunions in 50 patients treated with indirect reduction techniques and laterally based plating alone without use of allograft. A combination of cables, locking, and nonlocking screws were used. Critical to their technique was preservation of the soft tissue envelope at the level of the fracture.
In further support of MIPO techniques, a systematic review of 1571 periprosthetic hip fractures reported significantly increased risk of nonunion with open approaches when compared to minimally invasive osteosynthesis,16 emphasizing the role of preservation of vascularity in treating these fractures.
Length of Fixation
For some time it was recommended that fixation of Vancouver B1 fractures end 2 cortical diameters below the level of the fracture.37,38 More recently there has been interest in the potential benefits of increased length of fixation.
A biomechanical study comparing long (20-hole) and short (12-hole) plates for periprosthetic fracture with regard to failure found no difference in failure rates between groups.39 While plate length did not appear to affect construct stiffness, the issue of subsequent fracture distal to the construct remains.
Moloney and colleagues40 proposed fixation of Vancouver B1 fractures using plates that span the length of the femur to the level of the femoral condyles to minimize peri-implant failures in osteoporotic patients. In 36 patients treated with standard-length plates, there were 2 fractures distal to the previous fixation compared to no subsequent fractures in 21 patients treated with spanning fixation.
Similarly, in Vancouver C fractures there is some evidence that fixation should span the femoral stem, regardless of available bone for fixation proximal to the fracture. Kubiak and colleagues41 found increasing load to failure and decreased cortical strain in a biomechanical model comparing plates that stop short of the femoral stem with those that span the stem.
Clinically, this concept is supported by Froberg and colleagues.12 In their series of 60 Vancouver B1 and C fractures treated with laterally based locked plating, 3 patients went on to refracture. All of these fractures occurred in patients with Vancouver C fractures treated with plates overlapping the preexisting stem by <50%. The fractures all occurred at the high stress area between the tip of the stem and the end of the plate.
Further support of extended plate length comes from Drew and colleagues,8 who demonstrated a significantly decreased risk of reoperation following ORIF of periprosthetic femur fracture when >75% of the length of the femur was spanned compared to <50%. Although in some settings short fixation may produce satisfactory results, consideration should be given to extending the length of fixation, especially in the osteoporotic population.
Interprosthetic Fractures
With a rising number of patients with ipsilateral hip and knee arthroplasty, the rate of interprosthetic fractures is rising. These fractures present additional challenges given preexisting implants above and below the level of the fracture. The use of a single precontoured laterally based locked plate has been reported with good union rates approaching 90%.42,43 In one series, all nonunions occurred in Vancouver B1 fractures,43 again bringing to light the challenging nature of the B1 fracture.
Nonunion
Success in treating periprosthetic femur fractures has improved with improved fixation methods and understanding of technique. However, current rates of nonunion are still reported up to 27% for B1 and C fractures.44
There is limited evidence on the treatment of periprosthetic femur fracture nonunion. However, treatment is difficult and complication rates are high. Crockarell and colleagues45 reported a 52% overall complication rate in their series of 23 periprosthetic femur fracture nonunions.
Nonunions of the femur near a prosthesis can be treated by revision of the fracture fixation using compression and grafting to achieve bone healing vs revision of the joint prosthesis to span the area of the nonunited bone. Case-by-case decision-making is based on the remaining bone stock and the type of revision prosthesis necessary to span the problem area. Given the challenges associated with their treatment, a focus on prevention of nonunion is of paramount importance.
Authors’ Preferred Treatment
Our treatment of periprosthetic femur fractures with a well-fixed hip arthroplasty stem adheres to the principles supported in the literature (Figures 1A-1D and Figures 2A, 2B).
- Soft tissue friendly dissection with limited exposure at the fracture site is preferred as the fracture allows, particularly in cases with comminution where a direct assessment of the reduction is not available.
- Plate fixation strategy is dictated by the characteristics of the fracture. Fracture patterns amenable to anatomic reduction receive interfragmentary compression and absolute stability constructs. Highly comminuted fractures receive relatively stable bridging constructs to encourage callous.
- Locking screws are used rarely in diaphyseal fracture patterns, and when employed, are applied to only one side of the fracture to limit “over stiffening” the construct.
- Liberal use of dual plating, both as a method of maintaining fracture reduction while a structural plate is applied and increasing construct rigidity.
- Proximal fixation relies heavily on bicortical screws placed through the holes of the lateral plate. Cerclage wires and unicortical screws are rarely used in our practice. In the case of larger stems, a bicortical 3.5-mm screw can be placed through a 4.5-mm plate using a reduction washer.
Summary
Techniques for treatment of periprosthetic femur fractures around a well-fixed hip arthroplasty stem are constantly evolving. Several principles have emerged to decrease rates of treatment failure and subsequent reoperation. While there are several methods to do so, it is critical to achieve stable proximal fixation. Long spanning fixation constructs are linked to lower failure and reoperation rates in both B1 and C type fractures. Additionally, the importance of soft tissue management and maintenance of local vascularity should not be underestimated.
1. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785.
2. Lewallen DG, Berry DJ. Periprosthetic fracture of the femur after total hip arthroplasty: treatment and results to date. Instr Course Lect. 1998;47:243-249.
3. Kavanagh BF. Femoral fractures associated with total hip arthroplasty. Orthop Clin North Am. 1992;23(2):249-257.
4. Meek RM, Norwood T, Smith R, Brenkel IJ, Howie CR. The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg Br. 2011;93(1):96-101.
5. Abdel MP, Watts CD, Houdek MT, Lewallen DG, Berry DJ. Epidemiology of periprosthetic fracture of the femur in 32 644 primary total hip arthroplasties: a 40-year experience. Bone Joint J. 2016;98-B(4):461-467.
6. Berry DJ. Epidemiology: hip and knee. Orthop Clin North Am. 1999;30(2):183-190.
7. Abdel MP, Houdek MT, Watts CD, Lewallen DG, Berry DJ. Epidemiology of periprosthetic femoral fractures in 5417 revision total hip arthrolasties: a 40-year experience. Bone Joint J. 2016;98-B(4):468-474.
8. Drew JM, Griffin WL, Odum SM, Van Doren B, Weston BT, Stryker LS. Survivorship after periprosthetic femur fracture: factors affecting outcome. J Arthroplasty. 2015. [Epub ahead of print]
9. Dehghan N, McKee MD, Nauth A, Ristevski B, Schemitsch EH. Surgical fixation of Vancouver type B1 periprosthetic femur fractures: a systematic review. J Orthop Trauma. 2014;28(12):721-727.
10. Mukundan C, Rayan F, Kheir E, Macdonald D. Management of late periprosthetic femur fractures: a retrospective cohort of 72 patients. Int Orthop. 2010;34(4):485-489.
11. Lindahl H, Malchau H, Odén A, Garellick G. Risk factors for failure after treatment of a periprosthetic fracture of the femur. J Bone Joint Surg Br. 2006;88(1):26-30.
12. Froberg L, Troelsen A, Brix M. Periprosthetic Vancouver type B1 and C fractures treated by locking-plate osteosynthesis: fracture union and reoperations in 60 consecutive fractures. Acta Orthop. 2012;83(6):648-652.
13. Beals RK, Tower SS. Periprosthetic fractures of the femur. An analysis of 93 fractures. Clin Orthop Relat Res. 1996(327):238-246.
14. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br. 2002;84(8):1093-1110.
15. Fulkerson E, Koval K, Preston CF, Iesaka K, Kummer FJ, Egol KA. Fixation of periprosthetic femoral shaft fractures associated with cemented femoral stems: a biomechanical comparison of locked plating and conventional cable plates. J Orthop Trauma. 2006;20(2):89-93.
16. Stoffel K, Sommer C, Kalampoki V, Blumenthal A, Joeris A. The influence of the operation technique and implant used in the treatment of periprosthetic hip and interprosthetic femur fractures: a systematic literature review of 1571 cases. Arch Orthop Trauma Surg. 2016;136(4):553-561.
17. Fulkerson E, Tejwani N, Stuchin S, Egol K. Management of periprosthetic femur fractures with a first generation locking plate. Injury. 2007;38(8):965-972.
18. Ricci WM, Bolhofner BR, Loftus T, Cox C, Mitchell S, Borrelli J Jr. Indirect reduction and plate fixation, without grafting, for periprosthetic femoral shaft fractures about a stable intramedullary implant. Surgical technique. J Bone Joint Surg Am. 2006;88 Suppl 1 Pt 2:275-282.
19. Ebraheim NA, Gomez C, Ramineni SK, Liu J. Fixation of periprosthetic femoral shaft fractures adjacent to a well-fixed femoral stem with reversed distal femoral locking plate. J Trauma. 2009;66(4):1152-1157.
20. Bryant GK, Morshed S, Agel J, et al. Isolated locked compression plating for Vancouver Type B1 periprosthetic femoral fractures. Injury. 2009;40(11):1180-1186.
21. Giesinger K, Ebneter L, Day RE, Stoffel KK, Yates PJ, Kuster MS. Can plate osteosynthesis of periprosthethic femoral fractures cause cement mantle failure around a stable hip stem? A biomechanical analysis. J Arthroplasty. 2014;29(6):1308-1312.
22. Lewis GS, Caroom CT, Wee H, et al. Tangential bicortical locked fixation improves stability in vancouver B1 periprosthetic femur fractures: a biomechanical study. J Orthop Trauma. 2015;29(10):e364-e370.
23. Lenz M, Perren SM, Gueorguiev B, et al. A biomechanical study on proximal plate fixation techniques in periprosthetic femur fractures. Injury. 2014;45 Suppl 1:S71-S75.
24. Dennis MG, Simon JA, Kummer FJ, Koval KJ, DiCesare PE. Fixation of periprosthetic femoral shaft fractures occurring at the tip of the stem: a biomechanical study of 5 techniques. J Arthroplasty. 2000;15(4):523-528.
25. Graham SM, Mak JH, Moazen M, et al. Periprosthetic femoral fracture fixation: a biomechanical comparison between proximal locking screws and cables. J Orthop Sci. 2015;20(5):875-880.
26. Griffiths JT, Taheri A, Day RE, Yates PJ. Better axial stiffness of a bicortical screw construct compared to a cable construct for comminuted Vancouver B1 proximal femoral fractures. J Arthroplasty. 2015;30(12):2333-2337.
27. Chandler HP, King D, Limbird R, et al. The use of cortical allograft struts for fixation of fractures associated with well-fixed total joint prostheses. Semin Arthroplasty. 1993;4(2):99-107.
28. Haddad FS, Duncan CP, Berry DJ, Lewallen DG, Gross AE, Chandler HP. Periprosthetic femoral fractures around well-fixed implants: use of cortical onlay allografts with or without a plate. J Bone Joint Surg Am. 2002;84-A(6):945-950.
29. Dennis MG, Simon JA, Kummer FJ, Koval KJ, Di Cesare PE. Fixation of periprosthetic femoral shaft fractures: a biomechanical comparison of two techniques. J Orthop Trauma. 2001;15(3):177-180.
30. Yeo I, Rhyu KH, Kim SM, Park YS, Lim SJ. High union rates of locking compression plating with cortical strut allograft for type B1 periprosthetic femoral fractures. Int Orthop. 2016. [Epub ahead of print]
31. Khashan M, Amar E, Drexler M, Chechik Ok, Cohen Z, Steinberg EL. Superior outcome of strut allograft-augmented plate fixation for the treatment of periprosthetic fractures around a stable femoral stem. Injury. 2013;44(11):1556-1560.
32. Old AB, McGrory BJ, White RR, Babikian GM. Fixation of Vancouver B1 peri-prosthetic fractures by broad metal plates without the application of strut allografts. J Bone Joint Surg Br. 2006;88(11):1425-1429.
33. Moore RE, Baldwin K, Austin MS, Mehta S. A systematic review of open reduction and internal fixation of periprosthetic femur fractures with or without allograft strut, cerclage, and locked plates. J Arthroplasty. 2014;29(5):872-876.
34. Lenz M, Stoffel K, Gueorguiev B, Klos K, Kielstein H, Hofmann GO. Enhancing fixation strength in periprosthetic femur fractures by orthogonal plating-a biomechanical study. J Orthop Res. 2016;34(4):591-596.
35. Choi JK, Gardner TR, Yoon E, Morrison TA, Macaulay WB, Geller JA. The effect of fixation technique on the stiffness of comminuted Vancouver B1 periprosthetic femur fractures. J Arthroplasty. 2010;25(6 Suppl):124-128.
36. Müller FJ, Galler M Füchtmeier B. Clinical and radiological results of patients treated with orthogonal double plating for periprosthetic femoral fractures. Int Orthop. 2014;38(12):2469-2472.
37. Pike J, Davidson D, Garbuz D, Duncan CP, O’Brien PJ, Masri BA. Principles of treatment for periprosthetic femoral shaft fractures around well-fixed total hip arthroplasty. J Am Acad Orthop Surg. 2009;17(11):677-688.
38. Serocki JH, Chandler RW, Dorr LD. Treatment of fractures about hip prostheses with compression plating. J Arthroplasty. 1992;7(2):129-135.
39. Pletka JD, Marsland D, Belkoff SM, Mears SC, Kates SL. Biomechanical comparison of 2 different locking plate fixation methods in vancouver b1 periprosthetic femur fractures. Geriatr Orthop Surg Rehabil. 2011;2(2):51-55.
40. Moloney GB, Westrick ER, Siska PA, Tarkin IS. Treatment of periprosthetic femur fractures around a well-fixed hip arthroplasty implant: span the whole bone. Arch Orthop Trauma Surg. 2014;134(1):9-14.
41. Kubiak EN, Haller JM, Kemper DD, Presson AP, Higgins TF, Horowitz DS. Does the lateral plate need to overlap the stem to mitigate stress concentration when treating Vancouver C periprosthetic supracondylar femur fracture? J Arthroplasty. 2015;30(1):104-108.
42. Sah AP, Marshall A, Virkus WV, Estok DM 2nd, Della Valle CJ. Interprosthetic fractures of the femur: treatment with a single-locked plate. J Arthroplasty. 2010;25(2):280-286.
43. Hoffmann MF, Lotzien S, Schildhauer TA. Clinical outcome of interprosthetic femoral fractures treated with polyaxial locking plates. Injury. 2016. [Epub ahead of print]
44. Holder N, Papp S, Gofton W, Beaulé PE. Outcomes following surgical treatment of periprosthetic femur fractures: a single centre series. Can J Surg. 2014;57(3):209-213.
45. Crockarell JR Jr, Berry DJ, Lewallen DG. Nonunion after periprosthetic femoral fracture associated with total hip arthroplasty. J Bone Joint Surg Am. 1999;81(8):1073-1079.
1. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785.
2. Lewallen DG, Berry DJ. Periprosthetic fracture of the femur after total hip arthroplasty: treatment and results to date. Instr Course Lect. 1998;47:243-249.
3. Kavanagh BF. Femoral fractures associated with total hip arthroplasty. Orthop Clin North Am. 1992;23(2):249-257.
4. Meek RM, Norwood T, Smith R, Brenkel IJ, Howie CR. The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg Br. 2011;93(1):96-101.
5. Abdel MP, Watts CD, Houdek MT, Lewallen DG, Berry DJ. Epidemiology of periprosthetic fracture of the femur in 32 644 primary total hip arthroplasties: a 40-year experience. Bone Joint J. 2016;98-B(4):461-467.
6. Berry DJ. Epidemiology: hip and knee. Orthop Clin North Am. 1999;30(2):183-190.
7. Abdel MP, Houdek MT, Watts CD, Lewallen DG, Berry DJ. Epidemiology of periprosthetic femoral fractures in 5417 revision total hip arthrolasties: a 40-year experience. Bone Joint J. 2016;98-B(4):468-474.
8. Drew JM, Griffin WL, Odum SM, Van Doren B, Weston BT, Stryker LS. Survivorship after periprosthetic femur fracture: factors affecting outcome. J Arthroplasty. 2015. [Epub ahead of print]
9. Dehghan N, McKee MD, Nauth A, Ristevski B, Schemitsch EH. Surgical fixation of Vancouver type B1 periprosthetic femur fractures: a systematic review. J Orthop Trauma. 2014;28(12):721-727.
10. Mukundan C, Rayan F, Kheir E, Macdonald D. Management of late periprosthetic femur fractures: a retrospective cohort of 72 patients. Int Orthop. 2010;34(4):485-489.
11. Lindahl H, Malchau H, Odén A, Garellick G. Risk factors for failure after treatment of a periprosthetic fracture of the femur. J Bone Joint Surg Br. 2006;88(1):26-30.
12. Froberg L, Troelsen A, Brix M. Periprosthetic Vancouver type B1 and C fractures treated by locking-plate osteosynthesis: fracture union and reoperations in 60 consecutive fractures. Acta Orthop. 2012;83(6):648-652.
13. Beals RK, Tower SS. Periprosthetic fractures of the femur. An analysis of 93 fractures. Clin Orthop Relat Res. 1996(327):238-246.
14. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br. 2002;84(8):1093-1110.
15. Fulkerson E, Koval K, Preston CF, Iesaka K, Kummer FJ, Egol KA. Fixation of periprosthetic femoral shaft fractures associated with cemented femoral stems: a biomechanical comparison of locked plating and conventional cable plates. J Orthop Trauma. 2006;20(2):89-93.
16. Stoffel K, Sommer C, Kalampoki V, Blumenthal A, Joeris A. The influence of the operation technique and implant used in the treatment of periprosthetic hip and interprosthetic femur fractures: a systematic literature review of 1571 cases. Arch Orthop Trauma Surg. 2016;136(4):553-561.
17. Fulkerson E, Tejwani N, Stuchin S, Egol K. Management of periprosthetic femur fractures with a first generation locking plate. Injury. 2007;38(8):965-972.
18. Ricci WM, Bolhofner BR, Loftus T, Cox C, Mitchell S, Borrelli J Jr. Indirect reduction and plate fixation, without grafting, for periprosthetic femoral shaft fractures about a stable intramedullary implant. Surgical technique. J Bone Joint Surg Am. 2006;88 Suppl 1 Pt 2:275-282.
19. Ebraheim NA, Gomez C, Ramineni SK, Liu J. Fixation of periprosthetic femoral shaft fractures adjacent to a well-fixed femoral stem with reversed distal femoral locking plate. J Trauma. 2009;66(4):1152-1157.
20. Bryant GK, Morshed S, Agel J, et al. Isolated locked compression plating for Vancouver Type B1 periprosthetic femoral fractures. Injury. 2009;40(11):1180-1186.
21. Giesinger K, Ebneter L, Day RE, Stoffel KK, Yates PJ, Kuster MS. Can plate osteosynthesis of periprosthethic femoral fractures cause cement mantle failure around a stable hip stem? A biomechanical analysis. J Arthroplasty. 2014;29(6):1308-1312.
22. Lewis GS, Caroom CT, Wee H, et al. Tangential bicortical locked fixation improves stability in vancouver B1 periprosthetic femur fractures: a biomechanical study. J Orthop Trauma. 2015;29(10):e364-e370.
23. Lenz M, Perren SM, Gueorguiev B, et al. A biomechanical study on proximal plate fixation techniques in periprosthetic femur fractures. Injury. 2014;45 Suppl 1:S71-S75.
24. Dennis MG, Simon JA, Kummer FJ, Koval KJ, DiCesare PE. Fixation of periprosthetic femoral shaft fractures occurring at the tip of the stem: a biomechanical study of 5 techniques. J Arthroplasty. 2000;15(4):523-528.
25. Graham SM, Mak JH, Moazen M, et al. Periprosthetic femoral fracture fixation: a biomechanical comparison between proximal locking screws and cables. J Orthop Sci. 2015;20(5):875-880.
26. Griffiths JT, Taheri A, Day RE, Yates PJ. Better axial stiffness of a bicortical screw construct compared to a cable construct for comminuted Vancouver B1 proximal femoral fractures. J Arthroplasty. 2015;30(12):2333-2337.
27. Chandler HP, King D, Limbird R, et al. The use of cortical allograft struts for fixation of fractures associated with well-fixed total joint prostheses. Semin Arthroplasty. 1993;4(2):99-107.
28. Haddad FS, Duncan CP, Berry DJ, Lewallen DG, Gross AE, Chandler HP. Periprosthetic femoral fractures around well-fixed implants: use of cortical onlay allografts with or without a plate. J Bone Joint Surg Am. 2002;84-A(6):945-950.
29. Dennis MG, Simon JA, Kummer FJ, Koval KJ, Di Cesare PE. Fixation of periprosthetic femoral shaft fractures: a biomechanical comparison of two techniques. J Orthop Trauma. 2001;15(3):177-180.
30. Yeo I, Rhyu KH, Kim SM, Park YS, Lim SJ. High union rates of locking compression plating with cortical strut allograft for type B1 periprosthetic femoral fractures. Int Orthop. 2016. [Epub ahead of print]
31. Khashan M, Amar E, Drexler M, Chechik Ok, Cohen Z, Steinberg EL. Superior outcome of strut allograft-augmented plate fixation for the treatment of periprosthetic fractures around a stable femoral stem. Injury. 2013;44(11):1556-1560.
32. Old AB, McGrory BJ, White RR, Babikian GM. Fixation of Vancouver B1 peri-prosthetic fractures by broad metal plates without the application of strut allografts. J Bone Joint Surg Br. 2006;88(11):1425-1429.
33. Moore RE, Baldwin K, Austin MS, Mehta S. A systematic review of open reduction and internal fixation of periprosthetic femur fractures with or without allograft strut, cerclage, and locked plates. J Arthroplasty. 2014;29(5):872-876.
34. Lenz M, Stoffel K, Gueorguiev B, Klos K, Kielstein H, Hofmann GO. Enhancing fixation strength in periprosthetic femur fractures by orthogonal plating-a biomechanical study. J Orthop Res. 2016;34(4):591-596.
35. Choi JK, Gardner TR, Yoon E, Morrison TA, Macaulay WB, Geller JA. The effect of fixation technique on the stiffness of comminuted Vancouver B1 periprosthetic femur fractures. J Arthroplasty. 2010;25(6 Suppl):124-128.
36. Müller FJ, Galler M Füchtmeier B. Clinical and radiological results of patients treated with orthogonal double plating for periprosthetic femoral fractures. Int Orthop. 2014;38(12):2469-2472.
37. Pike J, Davidson D, Garbuz D, Duncan CP, O’Brien PJ, Masri BA. Principles of treatment for periprosthetic femoral shaft fractures around well-fixed total hip arthroplasty. J Am Acad Orthop Surg. 2009;17(11):677-688.
38. Serocki JH, Chandler RW, Dorr LD. Treatment of fractures about hip prostheses with compression plating. J Arthroplasty. 1992;7(2):129-135.
39. Pletka JD, Marsland D, Belkoff SM, Mears SC, Kates SL. Biomechanical comparison of 2 different locking plate fixation methods in vancouver b1 periprosthetic femur fractures. Geriatr Orthop Surg Rehabil. 2011;2(2):51-55.
40. Moloney GB, Westrick ER, Siska PA, Tarkin IS. Treatment of periprosthetic femur fractures around a well-fixed hip arthroplasty implant: span the whole bone. Arch Orthop Trauma Surg. 2014;134(1):9-14.
41. Kubiak EN, Haller JM, Kemper DD, Presson AP, Higgins TF, Horowitz DS. Does the lateral plate need to overlap the stem to mitigate stress concentration when treating Vancouver C periprosthetic supracondylar femur fracture? J Arthroplasty. 2015;30(1):104-108.
42. Sah AP, Marshall A, Virkus WV, Estok DM 2nd, Della Valle CJ. Interprosthetic fractures of the femur: treatment with a single-locked plate. J Arthroplasty. 2010;25(2):280-286.
43. Hoffmann MF, Lotzien S, Schildhauer TA. Clinical outcome of interprosthetic femoral fractures treated with polyaxial locking plates. Injury. 2016. [Epub ahead of print]
44. Holder N, Papp S, Gofton W, Beaulé PE. Outcomes following surgical treatment of periprosthetic femur fractures: a single centre series. Can J Surg. 2014;57(3):209-213.
45. Crockarell JR Jr, Berry DJ, Lewallen DG. Nonunion after periprosthetic femoral fracture associated with total hip arthroplasty. J Bone Joint Surg Am. 1999;81(8):1073-1079.
Using 3-Dimensional Fluoroscopy to Assess Acute Clavicle Fracture Displacement: A Radiographic Study
Clavicle fractures are common injuries, accounting for 2.6% to 5% of all adult fractures.1,2 Most clavicle fractures (69%-82%) occur in the middle third or midshaft.3,4 Midshaft clavicle fractures are often treated successfully with nonoperative means consisting of shoulder immobilization with either a sling or a figure-of-8 brace. Operative indications historically have been limited to open or impending open injuries and to patients with underlying neurovascular compromise. However, recent clinical studies have found that fractures with particular characteristics may benefit from surgical fixation. Important relative indications for open reduction and internal fixation of midshaft clavicle fractures are complete fracture fragment displacement with no cortical contact, and fractures with axial shortening of more than 20 mm.5,6
Accurately determining the extent of displacement and shortening can therefore be important in guiding treatment recommendations. The standard radiographic view for a clavicle fracture is upright or supine anteroposterior (AP). Typically, an AP radiograph with cephalic tilt of about 20° is obtained as well. On occasion, other supplemental radiographs, such as a 45° angulated view, as originally described by Quesada,7 are obtained. To our knowledge, the literature includes only 2 reports of studies that have compared different radiographic views and their accuracy in measuring fracture shortening8,9; no study has determined the best radiographic view for evaluating fracture displacement.
We conducted a study to determine which radiographic view best captures the most fracture fragment displacement. Acute midshaft clavicle fractures were assessed with simulated angled radiographs created from preoperative upright 3-dimensional (3-D) fluoroscopy scans. Our hypothesis was that a radiographic view with 20° of cephalic tilt would most often detect the most fracture displacement. In addition, we retrospectively reviewed our study patients’ initial AP injury radiographs to determine if obtaining a different view at maximum displacement would have helped identify a larger number of completely displaced midshaft clavicle fractures.
Patients and Methods
Institutional review board approval was obtained. Using our institution’s trauma registry database, we retrospectively identified 10 cases of patients who had undergone preoperative 3-D fluoroscopy for midshaft clavicle fractures. Study inclusion criteria were age 18 years or older, acute midshaft clavicle fracture, and preoperative 3-D fluoroscopy scan of clavicle available. Pediatric patients, nonacute injuries, and clavicle fractures of the lateral or medial third were excluded.
Three-dimensional fluoroscopy was used when the treating surgeon deemed it necessary for preoperative planning. All imaging was performed with a Philips MultiDiagnost Eleva 3-D fluoroscopy imager with patients in the upright standing position. (Informed patient consent was obtained.) Software bundled with the imager was used to create representative radiographs of differing angulation.
The common practice at most institutions is to obtain 2 radiographic views as part of a standard clavicle series. The additional AP angulated radiograph typically is obtained with 20° to 45° cephalic tilt from the horizontal axis. Therefore, simulated radiographs ranging from 15° to 50° of angulation in 5° increments were created, and the amount of superior displacement of the medial fragment was measured. As the simulated views were constructed from a 3-D composite image, there was none of the magnification error that occurs with AP or posteroanterior (PA) views. The stated degree of angulation mimics a radiograph’s AP cephalic tilt or PA caudal tilt (Figures 1A, 1B). For all radiographic images, displacement between fracture fragments was determined by measuring the distance between the superior cortices at the fracture site of the medial and lateral fragments. Each simulated radiograph was measured by 2 readers using standard computerized radiographic measurement tools. Final displacement was taken as the mean of the 2 measurements.
After determining which radiographic angulation demonstrated the largest number of maximally displaced fractures, we compared the simulated radiographs at that angulation with the injury AP images for all patients. Total number of patients with a completely displaced midshaft clavicle fracture and no cortical contact was recorded for the 2 radiographic views.
The Orthopaedic Trauma Association classification system8 was used to classify the clavicle fractures. Statistical analysis was performed with the Fisher exact test and a regression model, using SPSS Version 19.0 (IBM SPSS Statistics).
Results
Ten patients met the study inclusion criteria. Mean age was 32.9 years (range, 18-65 years). Seven of the 10 patients were male. Six patients had right-side clavicle fractures. Of the 10 patients, 5 had the comminuted wedge fracture pattern (15-B2.3), 2 had the simple spiral pattern (15-B1.1), 2 had the spiral wedge pattern (15-B2.1), and 1 had the oblique pattern (15-B1.2).
Table 1 summarizes the fracture displacement measurements obtained with the different radiographic views. Of the 10 cases, 5 showed the most displacement with the 15° tilted view (P = .004), and the other 5 showed maximum displacement with different radiographic angulations. In addition, 6 patients showed the least displacement with the 50° angulated view (P < .001). Results of the regression analysis are summarized in Tables 2 and 3.
Initial horizontal AP imaging showed completely displaced midshaft clavicle fractures in 9 of the 10 patients, and 15° simulated radiographs showed completely displaced fractures in all 10 patients (P = .50).
Discussion
Our study results demonstrated that an upright 15° radiographic tilt (AP cephalad or PA caudal) identified the most fracture displacement in the most patients with acute midshaft clavicle fractures. To our knowledge, this is the first study to identify the radiographic angulation that best shows the most clavicle fracture fragment displacement.
Other investigators have studied the accuracy of different radiographic views in the assessment of midshaft clavicle fractures, but they concentrated on fracture shortening. Smekal and colleagues9 used computed tomography (CT) and 3 different radiographic views to evaluate malunited midshaft clavicle fractures. Comparing the horizontal clavicular length measurements obtained with radiographs and CT scans, they determined that PA thoracic radiographs were in highest agreement with the CT scans. The results, however, were not statistically significant. In their study, supine CT was successful because the fractures were healed, and the displacement and shortening amounts were not affected by patient position. Sharr and Mohammed10 studied the accuracy of different views in the assessment of clavicle length in an articulated cadaver specimen. They obtained multiple AP and PA radiographs of different horizontal (medial, lateral) and vertical (cephalad, caudal) angulations. Actual clavicle length was then directly measured and compared with the length measured on the different views. The authors concluded that a PA 15° caudal radiograph was most accurate in assessing clavicular length. Both Smekal and colleagues9 and Sharr and Mohammed10 recommended the PA radiograph because it decreases the degree of magnification on AP radiographs by minimizing the film-to-object distance.
Our findings are important because more accurate determination of fracture displacement in patients with midshaft clavicle fractures may change clinical management. Nowak and colleagues11 investigated various patient and clavicle fracture characteristics that were predictive of a higher rate of long-term sequelae. They found that complete fracture displacement was the strongest radiographic predictor of patients’ beliefs that they were fully recovered from injury at final follow-up. The authors concluded that fractures with no bony contact should receive more “active” management. Robinson and colleagues12 studied a cohort of patients with nonoperatively managed midshaft clavicle fractures and concluded that complete fracture displacement significantly increased risk for nonunion (this risk was 2.3 times higher in patients with displaced fractures than in patients with nondisplaced fractures). Last, McKee and colleagues13 found that shoulder strength and endurance were significantly decreased in nonoperatively treated displaced midshaft clavicle fractures than in the same patients’ uninjured shoulders.
Extending the results of these studies, recent prospective randomized control trials and a meta-analysis have compared the clinical outcomes of nonoperatively and operatively managed displaced midshaft clavicle fractures.14-18 With few exceptions, these studies found improved clinical results with operative fixation. In one such study, the Canadian Orthopaedic Trauma Society14 randomized patients with displaced midshaft clavicle fractures to either operative plate fixation or sling immobilization. The operative group was found to have improved Disability of the Arm, Shoulder, and Hand scores, improved Constant shoulder scores, increased patient satisfaction, faster mean time to bony fracture union, higher satisfaction with shoulder appearance, and lower rates of nonunion and malunion. Given the results of these studies, accurate identification of a displaced midshaft clavicle fracture with no cortical contact is fundamental in deciding whether to recommend operative fixation.
Retrospective review of our cohort’s initial radiographs revealed 1 case in which the patient’s completely displaced midshaft clavicle fracture would not have been diagnosed solely with an AP horizontal image. Cortical contact was seen on a standard AP clavicle radiograph (Figures 2A, 2B), and a 15° tilt radiograph created from 3-D fluoroscopy scan showed complete fracture fragment displacement (Figure 3). A change in fracture classification from partially displaced to fully displaced could alter the type of management used by a treating surgeon.
There were obvious weaknesses to this study. First, its sample size was small (10 patients). Nevertheless, we had sufficient numbers to find a statistically significant angulation. Second, a wider range of radiographic angles could have been studied. Our intent, however, was to investigate the accuracy of the 2 most common supplementary clavicle views (20° and 45° cephalic tilt). Therefore, we selected a range of simulated radiographs that began 5° outside these angulations. Third, we measured only the degree of fracture displacement; we were unable to accurately access fracture shortening, as the 3-D fluoroscopic images were limited to the injured clavicles. A potential solution to this problem is to widen the exposure field in order to include the entire chest and allow clavicular length comparison against the uninjured side. Doing this would have been possible, but at the expense of increasing the patient’s radiation exposure.
This innovative study used 3-D fluoroscopy to capture clavicle fracture images with patients in an upright position. Unlike standard CT, in which patients are supine, this 3-D imaging technology better emulates the patient positioning used for upright radiographs, thereby avoiding potential fracture fragment alignment changes caused by shifts in body position. In addition, 3-D fluoroscopy allows us to create multiple precise simulated radiographic angulations without the magnification error of AP radiographs and, to a lesser extent, PA radiographs. Having a standing PA 15° caudal tilt radiograph obviates the need for CT with 3-D reconstruction. More fine detail may be revealed by CT with 3-D reconstruction than by a standing PA 15° caudal tilt radiograph, but the patient faces less radiation risk and cost with the radiograph.
There is no consensus as to what constitutes the standard radiographic series for clavicle fractures. Radiographic technique can vary with respect to supplemental view angulation, supine or upright patient positioning, and AP or PA radiographic views. Although our study did not address the effect of supine versus upright patient positioning on acute midshaft clavicle fracture displacement, we think that, for all clinical and research purposes, upright 15° caudal PA radiographs should be obtained for patients with acute midshaft clavicle fractures.
Conclusion
Our retrospective study of 10 patients with acute midshaft clavicle fractures and preoperative upright 3-D fluoroscopy scans found that a 15° angulated radiograph most often demonstrated the most fracture fragment displacement. Given these findings, we recommend obtaining an additional PA 15° caudal radiograph in the upright position for patients with midshaft clavicle fractures to best assess the extent of fracture displacement. Accurately identifying the degree of fracture displacement is important, as operative management of completely displaced fractures has been shown to improve clinical outcomes.
1. Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg. 2002;11(5):452-456.
2. Nordqvist A, Petersson C. The incidence of fractures of the clavicle. Clin Orthop Relat Res. 1994;(300):127-132.
3. Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br. 1998;80(3):476-484.
4. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res. 1968;(58):29-42.
5. Jeray KJ. Acute midshaft clavicular fracture. J Am Acad Orthop Surg. 2007;15(4):239-248.
6. Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am. 2009;91(2):447-460.
7. Quesada F. Technique for the roentgen diagnosis of fractures of the clavicle. Surg Gynecol Obstet. 1926;42:424-428.
8. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association Classification, Database and Outcomes Committee. J Orthop Trauma. 2007;21(10 suppl):S1-S133.
9. Smekal V, Deml C, Irenberger A, et al. Length determination in midshaft clavicle fractures: validation of measurement. J Orthop Trauma. 2008;22(7):458-462.
10. Sharr JR, Mohammed KD. Optimizing the radiographic technique in clavicular fractures. J Shoulder Elbow Surg. 2003;12(2):170-172.
11. Nowak J, Holgersson M, Larsson S. Can we predict long-term sequelae after fractures of the clavicle based on initial findings? A prospective study with nine to ten years of follow-up. J Shoulder Elbow Surg. 2004;13(5):479-486.
12. Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am. 2004;86(7):1359-1365.
13. McKee MD, Pedersen EM, Jones C, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2006;88(1):35-40.
14. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89(1):1-10.
15. Judd DB, Pallis MP, Smith E, Bottoni CR. Acute operative stabilization versus nonoperative management of clavicle fractures. Am J Orthop. 2009;38(7):341-345.
16. Smekal V, Irenberger A, Struve P, Wambacher M, Krappinger D, Kralinger FS. Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures—a randomized, controlled, clinical trial. J Orthop Trauma. 2009;23(2):106-112.
17. Witzel K. Intramedullary osteosynthesis in fractures of the mid-third of the clavicle in sports traumatology [in German]. Z Orthop Unfall. 2007;145(5):639-642.
18. McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J Bone Joint Surg Am. 2012;94(8):675-684.
Clavicle fractures are common injuries, accounting for 2.6% to 5% of all adult fractures.1,2 Most clavicle fractures (69%-82%) occur in the middle third or midshaft.3,4 Midshaft clavicle fractures are often treated successfully with nonoperative means consisting of shoulder immobilization with either a sling or a figure-of-8 brace. Operative indications historically have been limited to open or impending open injuries and to patients with underlying neurovascular compromise. However, recent clinical studies have found that fractures with particular characteristics may benefit from surgical fixation. Important relative indications for open reduction and internal fixation of midshaft clavicle fractures are complete fracture fragment displacement with no cortical contact, and fractures with axial shortening of more than 20 mm.5,6
Accurately determining the extent of displacement and shortening can therefore be important in guiding treatment recommendations. The standard radiographic view for a clavicle fracture is upright or supine anteroposterior (AP). Typically, an AP radiograph with cephalic tilt of about 20° is obtained as well. On occasion, other supplemental radiographs, such as a 45° angulated view, as originally described by Quesada,7 are obtained. To our knowledge, the literature includes only 2 reports of studies that have compared different radiographic views and their accuracy in measuring fracture shortening8,9; no study has determined the best radiographic view for evaluating fracture displacement.
We conducted a study to determine which radiographic view best captures the most fracture fragment displacement. Acute midshaft clavicle fractures were assessed with simulated angled radiographs created from preoperative upright 3-dimensional (3-D) fluoroscopy scans. Our hypothesis was that a radiographic view with 20° of cephalic tilt would most often detect the most fracture displacement. In addition, we retrospectively reviewed our study patients’ initial AP injury radiographs to determine if obtaining a different view at maximum displacement would have helped identify a larger number of completely displaced midshaft clavicle fractures.
Patients and Methods
Institutional review board approval was obtained. Using our institution’s trauma registry database, we retrospectively identified 10 cases of patients who had undergone preoperative 3-D fluoroscopy for midshaft clavicle fractures. Study inclusion criteria were age 18 years or older, acute midshaft clavicle fracture, and preoperative 3-D fluoroscopy scan of clavicle available. Pediatric patients, nonacute injuries, and clavicle fractures of the lateral or medial third were excluded.
Three-dimensional fluoroscopy was used when the treating surgeon deemed it necessary for preoperative planning. All imaging was performed with a Philips MultiDiagnost Eleva 3-D fluoroscopy imager with patients in the upright standing position. (Informed patient consent was obtained.) Software bundled with the imager was used to create representative radiographs of differing angulation.
The common practice at most institutions is to obtain 2 radiographic views as part of a standard clavicle series. The additional AP angulated radiograph typically is obtained with 20° to 45° cephalic tilt from the horizontal axis. Therefore, simulated radiographs ranging from 15° to 50° of angulation in 5° increments were created, and the amount of superior displacement of the medial fragment was measured. As the simulated views were constructed from a 3-D composite image, there was none of the magnification error that occurs with AP or posteroanterior (PA) views. The stated degree of angulation mimics a radiograph’s AP cephalic tilt or PA caudal tilt (Figures 1A, 1B). For all radiographic images, displacement between fracture fragments was determined by measuring the distance between the superior cortices at the fracture site of the medial and lateral fragments. Each simulated radiograph was measured by 2 readers using standard computerized radiographic measurement tools. Final displacement was taken as the mean of the 2 measurements.
After determining which radiographic angulation demonstrated the largest number of maximally displaced fractures, we compared the simulated radiographs at that angulation with the injury AP images for all patients. Total number of patients with a completely displaced midshaft clavicle fracture and no cortical contact was recorded for the 2 radiographic views.
The Orthopaedic Trauma Association classification system8 was used to classify the clavicle fractures. Statistical analysis was performed with the Fisher exact test and a regression model, using SPSS Version 19.0 (IBM SPSS Statistics).
Results
Ten patients met the study inclusion criteria. Mean age was 32.9 years (range, 18-65 years). Seven of the 10 patients were male. Six patients had right-side clavicle fractures. Of the 10 patients, 5 had the comminuted wedge fracture pattern (15-B2.3), 2 had the simple spiral pattern (15-B1.1), 2 had the spiral wedge pattern (15-B2.1), and 1 had the oblique pattern (15-B1.2).
Table 1 summarizes the fracture displacement measurements obtained with the different radiographic views. Of the 10 cases, 5 showed the most displacement with the 15° tilted view (P = .004), and the other 5 showed maximum displacement with different radiographic angulations. In addition, 6 patients showed the least displacement with the 50° angulated view (P < .001). Results of the regression analysis are summarized in Tables 2 and 3.
Initial horizontal AP imaging showed completely displaced midshaft clavicle fractures in 9 of the 10 patients, and 15° simulated radiographs showed completely displaced fractures in all 10 patients (P = .50).
Discussion
Our study results demonstrated that an upright 15° radiographic tilt (AP cephalad or PA caudal) identified the most fracture displacement in the most patients with acute midshaft clavicle fractures. To our knowledge, this is the first study to identify the radiographic angulation that best shows the most clavicle fracture fragment displacement.
Other investigators have studied the accuracy of different radiographic views in the assessment of midshaft clavicle fractures, but they concentrated on fracture shortening. Smekal and colleagues9 used computed tomography (CT) and 3 different radiographic views to evaluate malunited midshaft clavicle fractures. Comparing the horizontal clavicular length measurements obtained with radiographs and CT scans, they determined that PA thoracic radiographs were in highest agreement with the CT scans. The results, however, were not statistically significant. In their study, supine CT was successful because the fractures were healed, and the displacement and shortening amounts were not affected by patient position. Sharr and Mohammed10 studied the accuracy of different views in the assessment of clavicle length in an articulated cadaver specimen. They obtained multiple AP and PA radiographs of different horizontal (medial, lateral) and vertical (cephalad, caudal) angulations. Actual clavicle length was then directly measured and compared with the length measured on the different views. The authors concluded that a PA 15° caudal radiograph was most accurate in assessing clavicular length. Both Smekal and colleagues9 and Sharr and Mohammed10 recommended the PA radiograph because it decreases the degree of magnification on AP radiographs by minimizing the film-to-object distance.
Our findings are important because more accurate determination of fracture displacement in patients with midshaft clavicle fractures may change clinical management. Nowak and colleagues11 investigated various patient and clavicle fracture characteristics that were predictive of a higher rate of long-term sequelae. They found that complete fracture displacement was the strongest radiographic predictor of patients’ beliefs that they were fully recovered from injury at final follow-up. The authors concluded that fractures with no bony contact should receive more “active” management. Robinson and colleagues12 studied a cohort of patients with nonoperatively managed midshaft clavicle fractures and concluded that complete fracture displacement significantly increased risk for nonunion (this risk was 2.3 times higher in patients with displaced fractures than in patients with nondisplaced fractures). Last, McKee and colleagues13 found that shoulder strength and endurance were significantly decreased in nonoperatively treated displaced midshaft clavicle fractures than in the same patients’ uninjured shoulders.
Extending the results of these studies, recent prospective randomized control trials and a meta-analysis have compared the clinical outcomes of nonoperatively and operatively managed displaced midshaft clavicle fractures.14-18 With few exceptions, these studies found improved clinical results with operative fixation. In one such study, the Canadian Orthopaedic Trauma Society14 randomized patients with displaced midshaft clavicle fractures to either operative plate fixation or sling immobilization. The operative group was found to have improved Disability of the Arm, Shoulder, and Hand scores, improved Constant shoulder scores, increased patient satisfaction, faster mean time to bony fracture union, higher satisfaction with shoulder appearance, and lower rates of nonunion and malunion. Given the results of these studies, accurate identification of a displaced midshaft clavicle fracture with no cortical contact is fundamental in deciding whether to recommend operative fixation.
Retrospective review of our cohort’s initial radiographs revealed 1 case in which the patient’s completely displaced midshaft clavicle fracture would not have been diagnosed solely with an AP horizontal image. Cortical contact was seen on a standard AP clavicle radiograph (Figures 2A, 2B), and a 15° tilt radiograph created from 3-D fluoroscopy scan showed complete fracture fragment displacement (Figure 3). A change in fracture classification from partially displaced to fully displaced could alter the type of management used by a treating surgeon.
There were obvious weaknesses to this study. First, its sample size was small (10 patients). Nevertheless, we had sufficient numbers to find a statistically significant angulation. Second, a wider range of radiographic angles could have been studied. Our intent, however, was to investigate the accuracy of the 2 most common supplementary clavicle views (20° and 45° cephalic tilt). Therefore, we selected a range of simulated radiographs that began 5° outside these angulations. Third, we measured only the degree of fracture displacement; we were unable to accurately access fracture shortening, as the 3-D fluoroscopic images were limited to the injured clavicles. A potential solution to this problem is to widen the exposure field in order to include the entire chest and allow clavicular length comparison against the uninjured side. Doing this would have been possible, but at the expense of increasing the patient’s radiation exposure.
This innovative study used 3-D fluoroscopy to capture clavicle fracture images with patients in an upright position. Unlike standard CT, in which patients are supine, this 3-D imaging technology better emulates the patient positioning used for upright radiographs, thereby avoiding potential fracture fragment alignment changes caused by shifts in body position. In addition, 3-D fluoroscopy allows us to create multiple precise simulated radiographic angulations without the magnification error of AP radiographs and, to a lesser extent, PA radiographs. Having a standing PA 15° caudal tilt radiograph obviates the need for CT with 3-D reconstruction. More fine detail may be revealed by CT with 3-D reconstruction than by a standing PA 15° caudal tilt radiograph, but the patient faces less radiation risk and cost with the radiograph.
There is no consensus as to what constitutes the standard radiographic series for clavicle fractures. Radiographic technique can vary with respect to supplemental view angulation, supine or upright patient positioning, and AP or PA radiographic views. Although our study did not address the effect of supine versus upright patient positioning on acute midshaft clavicle fracture displacement, we think that, for all clinical and research purposes, upright 15° caudal PA radiographs should be obtained for patients with acute midshaft clavicle fractures.
Conclusion
Our retrospective study of 10 patients with acute midshaft clavicle fractures and preoperative upright 3-D fluoroscopy scans found that a 15° angulated radiograph most often demonstrated the most fracture fragment displacement. Given these findings, we recommend obtaining an additional PA 15° caudal radiograph in the upright position for patients with midshaft clavicle fractures to best assess the extent of fracture displacement. Accurately identifying the degree of fracture displacement is important, as operative management of completely displaced fractures has been shown to improve clinical outcomes.
Clavicle fractures are common injuries, accounting for 2.6% to 5% of all adult fractures.1,2 Most clavicle fractures (69%-82%) occur in the middle third or midshaft.3,4 Midshaft clavicle fractures are often treated successfully with nonoperative means consisting of shoulder immobilization with either a sling or a figure-of-8 brace. Operative indications historically have been limited to open or impending open injuries and to patients with underlying neurovascular compromise. However, recent clinical studies have found that fractures with particular characteristics may benefit from surgical fixation. Important relative indications for open reduction and internal fixation of midshaft clavicle fractures are complete fracture fragment displacement with no cortical contact, and fractures with axial shortening of more than 20 mm.5,6
Accurately determining the extent of displacement and shortening can therefore be important in guiding treatment recommendations. The standard radiographic view for a clavicle fracture is upright or supine anteroposterior (AP). Typically, an AP radiograph with cephalic tilt of about 20° is obtained as well. On occasion, other supplemental radiographs, such as a 45° angulated view, as originally described by Quesada,7 are obtained. To our knowledge, the literature includes only 2 reports of studies that have compared different radiographic views and their accuracy in measuring fracture shortening8,9; no study has determined the best radiographic view for evaluating fracture displacement.
We conducted a study to determine which radiographic view best captures the most fracture fragment displacement. Acute midshaft clavicle fractures were assessed with simulated angled radiographs created from preoperative upright 3-dimensional (3-D) fluoroscopy scans. Our hypothesis was that a radiographic view with 20° of cephalic tilt would most often detect the most fracture displacement. In addition, we retrospectively reviewed our study patients’ initial AP injury radiographs to determine if obtaining a different view at maximum displacement would have helped identify a larger number of completely displaced midshaft clavicle fractures.
Patients and Methods
Institutional review board approval was obtained. Using our institution’s trauma registry database, we retrospectively identified 10 cases of patients who had undergone preoperative 3-D fluoroscopy for midshaft clavicle fractures. Study inclusion criteria were age 18 years or older, acute midshaft clavicle fracture, and preoperative 3-D fluoroscopy scan of clavicle available. Pediatric patients, nonacute injuries, and clavicle fractures of the lateral or medial third were excluded.
Three-dimensional fluoroscopy was used when the treating surgeon deemed it necessary for preoperative planning. All imaging was performed with a Philips MultiDiagnost Eleva 3-D fluoroscopy imager with patients in the upright standing position. (Informed patient consent was obtained.) Software bundled with the imager was used to create representative radiographs of differing angulation.
The common practice at most institutions is to obtain 2 radiographic views as part of a standard clavicle series. The additional AP angulated radiograph typically is obtained with 20° to 45° cephalic tilt from the horizontal axis. Therefore, simulated radiographs ranging from 15° to 50° of angulation in 5° increments were created, and the amount of superior displacement of the medial fragment was measured. As the simulated views were constructed from a 3-D composite image, there was none of the magnification error that occurs with AP or posteroanterior (PA) views. The stated degree of angulation mimics a radiograph’s AP cephalic tilt or PA caudal tilt (Figures 1A, 1B). For all radiographic images, displacement between fracture fragments was determined by measuring the distance between the superior cortices at the fracture site of the medial and lateral fragments. Each simulated radiograph was measured by 2 readers using standard computerized radiographic measurement tools. Final displacement was taken as the mean of the 2 measurements.
After determining which radiographic angulation demonstrated the largest number of maximally displaced fractures, we compared the simulated radiographs at that angulation with the injury AP images for all patients. Total number of patients with a completely displaced midshaft clavicle fracture and no cortical contact was recorded for the 2 radiographic views.
The Orthopaedic Trauma Association classification system8 was used to classify the clavicle fractures. Statistical analysis was performed with the Fisher exact test and a regression model, using SPSS Version 19.0 (IBM SPSS Statistics).
Results
Ten patients met the study inclusion criteria. Mean age was 32.9 years (range, 18-65 years). Seven of the 10 patients were male. Six patients had right-side clavicle fractures. Of the 10 patients, 5 had the comminuted wedge fracture pattern (15-B2.3), 2 had the simple spiral pattern (15-B1.1), 2 had the spiral wedge pattern (15-B2.1), and 1 had the oblique pattern (15-B1.2).
Table 1 summarizes the fracture displacement measurements obtained with the different radiographic views. Of the 10 cases, 5 showed the most displacement with the 15° tilted view (P = .004), and the other 5 showed maximum displacement with different radiographic angulations. In addition, 6 patients showed the least displacement with the 50° angulated view (P < .001). Results of the regression analysis are summarized in Tables 2 and 3.
Initial horizontal AP imaging showed completely displaced midshaft clavicle fractures in 9 of the 10 patients, and 15° simulated radiographs showed completely displaced fractures in all 10 patients (P = .50).
Discussion
Our study results demonstrated that an upright 15° radiographic tilt (AP cephalad or PA caudal) identified the most fracture displacement in the most patients with acute midshaft clavicle fractures. To our knowledge, this is the first study to identify the radiographic angulation that best shows the most clavicle fracture fragment displacement.
Other investigators have studied the accuracy of different radiographic views in the assessment of midshaft clavicle fractures, but they concentrated on fracture shortening. Smekal and colleagues9 used computed tomography (CT) and 3 different radiographic views to evaluate malunited midshaft clavicle fractures. Comparing the horizontal clavicular length measurements obtained with radiographs and CT scans, they determined that PA thoracic radiographs were in highest agreement with the CT scans. The results, however, were not statistically significant. In their study, supine CT was successful because the fractures were healed, and the displacement and shortening amounts were not affected by patient position. Sharr and Mohammed10 studied the accuracy of different views in the assessment of clavicle length in an articulated cadaver specimen. They obtained multiple AP and PA radiographs of different horizontal (medial, lateral) and vertical (cephalad, caudal) angulations. Actual clavicle length was then directly measured and compared with the length measured on the different views. The authors concluded that a PA 15° caudal radiograph was most accurate in assessing clavicular length. Both Smekal and colleagues9 and Sharr and Mohammed10 recommended the PA radiograph because it decreases the degree of magnification on AP radiographs by minimizing the film-to-object distance.
Our findings are important because more accurate determination of fracture displacement in patients with midshaft clavicle fractures may change clinical management. Nowak and colleagues11 investigated various patient and clavicle fracture characteristics that were predictive of a higher rate of long-term sequelae. They found that complete fracture displacement was the strongest radiographic predictor of patients’ beliefs that they were fully recovered from injury at final follow-up. The authors concluded that fractures with no bony contact should receive more “active” management. Robinson and colleagues12 studied a cohort of patients with nonoperatively managed midshaft clavicle fractures and concluded that complete fracture displacement significantly increased risk for nonunion (this risk was 2.3 times higher in patients with displaced fractures than in patients with nondisplaced fractures). Last, McKee and colleagues13 found that shoulder strength and endurance were significantly decreased in nonoperatively treated displaced midshaft clavicle fractures than in the same patients’ uninjured shoulders.
Extending the results of these studies, recent prospective randomized control trials and a meta-analysis have compared the clinical outcomes of nonoperatively and operatively managed displaced midshaft clavicle fractures.14-18 With few exceptions, these studies found improved clinical results with operative fixation. In one such study, the Canadian Orthopaedic Trauma Society14 randomized patients with displaced midshaft clavicle fractures to either operative plate fixation or sling immobilization. The operative group was found to have improved Disability of the Arm, Shoulder, and Hand scores, improved Constant shoulder scores, increased patient satisfaction, faster mean time to bony fracture union, higher satisfaction with shoulder appearance, and lower rates of nonunion and malunion. Given the results of these studies, accurate identification of a displaced midshaft clavicle fracture with no cortical contact is fundamental in deciding whether to recommend operative fixation.
Retrospective review of our cohort’s initial radiographs revealed 1 case in which the patient’s completely displaced midshaft clavicle fracture would not have been diagnosed solely with an AP horizontal image. Cortical contact was seen on a standard AP clavicle radiograph (Figures 2A, 2B), and a 15° tilt radiograph created from 3-D fluoroscopy scan showed complete fracture fragment displacement (Figure 3). A change in fracture classification from partially displaced to fully displaced could alter the type of management used by a treating surgeon.
There were obvious weaknesses to this study. First, its sample size was small (10 patients). Nevertheless, we had sufficient numbers to find a statistically significant angulation. Second, a wider range of radiographic angles could have been studied. Our intent, however, was to investigate the accuracy of the 2 most common supplementary clavicle views (20° and 45° cephalic tilt). Therefore, we selected a range of simulated radiographs that began 5° outside these angulations. Third, we measured only the degree of fracture displacement; we were unable to accurately access fracture shortening, as the 3-D fluoroscopic images were limited to the injured clavicles. A potential solution to this problem is to widen the exposure field in order to include the entire chest and allow clavicular length comparison against the uninjured side. Doing this would have been possible, but at the expense of increasing the patient’s radiation exposure.
This innovative study used 3-D fluoroscopy to capture clavicle fracture images with patients in an upright position. Unlike standard CT, in which patients are supine, this 3-D imaging technology better emulates the patient positioning used for upright radiographs, thereby avoiding potential fracture fragment alignment changes caused by shifts in body position. In addition, 3-D fluoroscopy allows us to create multiple precise simulated radiographic angulations without the magnification error of AP radiographs and, to a lesser extent, PA radiographs. Having a standing PA 15° caudal tilt radiograph obviates the need for CT with 3-D reconstruction. More fine detail may be revealed by CT with 3-D reconstruction than by a standing PA 15° caudal tilt radiograph, but the patient faces less radiation risk and cost with the radiograph.
There is no consensus as to what constitutes the standard radiographic series for clavicle fractures. Radiographic technique can vary with respect to supplemental view angulation, supine or upright patient positioning, and AP or PA radiographic views. Although our study did not address the effect of supine versus upright patient positioning on acute midshaft clavicle fracture displacement, we think that, for all clinical and research purposes, upright 15° caudal PA radiographs should be obtained for patients with acute midshaft clavicle fractures.
Conclusion
Our retrospective study of 10 patients with acute midshaft clavicle fractures and preoperative upright 3-D fluoroscopy scans found that a 15° angulated radiograph most often demonstrated the most fracture fragment displacement. Given these findings, we recommend obtaining an additional PA 15° caudal radiograph in the upright position for patients with midshaft clavicle fractures to best assess the extent of fracture displacement. Accurately identifying the degree of fracture displacement is important, as operative management of completely displaced fractures has been shown to improve clinical outcomes.
1. Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg. 2002;11(5):452-456.
2. Nordqvist A, Petersson C. The incidence of fractures of the clavicle. Clin Orthop Relat Res. 1994;(300):127-132.
3. Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br. 1998;80(3):476-484.
4. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res. 1968;(58):29-42.
5. Jeray KJ. Acute midshaft clavicular fracture. J Am Acad Orthop Surg. 2007;15(4):239-248.
6. Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am. 2009;91(2):447-460.
7. Quesada F. Technique for the roentgen diagnosis of fractures of the clavicle. Surg Gynecol Obstet. 1926;42:424-428.
8. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association Classification, Database and Outcomes Committee. J Orthop Trauma. 2007;21(10 suppl):S1-S133.
9. Smekal V, Deml C, Irenberger A, et al. Length determination in midshaft clavicle fractures: validation of measurement. J Orthop Trauma. 2008;22(7):458-462.
10. Sharr JR, Mohammed KD. Optimizing the radiographic technique in clavicular fractures. J Shoulder Elbow Surg. 2003;12(2):170-172.
11. Nowak J, Holgersson M, Larsson S. Can we predict long-term sequelae after fractures of the clavicle based on initial findings? A prospective study with nine to ten years of follow-up. J Shoulder Elbow Surg. 2004;13(5):479-486.
12. Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am. 2004;86(7):1359-1365.
13. McKee MD, Pedersen EM, Jones C, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2006;88(1):35-40.
14. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89(1):1-10.
15. Judd DB, Pallis MP, Smith E, Bottoni CR. Acute operative stabilization versus nonoperative management of clavicle fractures. Am J Orthop. 2009;38(7):341-345.
16. Smekal V, Irenberger A, Struve P, Wambacher M, Krappinger D, Kralinger FS. Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures—a randomized, controlled, clinical trial. J Orthop Trauma. 2009;23(2):106-112.
17. Witzel K. Intramedullary osteosynthesis in fractures of the mid-third of the clavicle in sports traumatology [in German]. Z Orthop Unfall. 2007;145(5):639-642.
18. McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J Bone Joint Surg Am. 2012;94(8):675-684.
1. Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg. 2002;11(5):452-456.
2. Nordqvist A, Petersson C. The incidence of fractures of the clavicle. Clin Orthop Relat Res. 1994;(300):127-132.
3. Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br. 1998;80(3):476-484.
4. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res. 1968;(58):29-42.
5. Jeray KJ. Acute midshaft clavicular fracture. J Am Acad Orthop Surg. 2007;15(4):239-248.
6. Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am. 2009;91(2):447-460.
7. Quesada F. Technique for the roentgen diagnosis of fractures of the clavicle. Surg Gynecol Obstet. 1926;42:424-428.
8. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association Classification, Database and Outcomes Committee. J Orthop Trauma. 2007;21(10 suppl):S1-S133.
9. Smekal V, Deml C, Irenberger A, et al. Length determination in midshaft clavicle fractures: validation of measurement. J Orthop Trauma. 2008;22(7):458-462.
10. Sharr JR, Mohammed KD. Optimizing the radiographic technique in clavicular fractures. J Shoulder Elbow Surg. 2003;12(2):170-172.
11. Nowak J, Holgersson M, Larsson S. Can we predict long-term sequelae after fractures of the clavicle based on initial findings? A prospective study with nine to ten years of follow-up. J Shoulder Elbow Surg. 2004;13(5):479-486.
12. Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am. 2004;86(7):1359-1365.
13. McKee MD, Pedersen EM, Jones C, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2006;88(1):35-40.
14. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89(1):1-10.
15. Judd DB, Pallis MP, Smith E, Bottoni CR. Acute operative stabilization versus nonoperative management of clavicle fractures. Am J Orthop. 2009;38(7):341-345.
16. Smekal V, Irenberger A, Struve P, Wambacher M, Krappinger D, Kralinger FS. Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures—a randomized, controlled, clinical trial. J Orthop Trauma. 2009;23(2):106-112.
17. Witzel K. Intramedullary osteosynthesis in fractures of the mid-third of the clavicle in sports traumatology [in German]. Z Orthop Unfall. 2007;145(5):639-642.
18. McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J Bone Joint Surg Am. 2012;94(8):675-684.
